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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374603402
Report Date: 07/25/2024
Date Signed: 07/25/2024 12:47:57 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/06/2021 and conducted by Evaluator Ramon Serrano
COMPLAINT CONTROL NUMBER: 08-AS-20210706135019
FACILITY NAME:FREDERICKA MANORFACILITY NUMBER:
374603402
ADMINISTRATOR:CRAIG SUMNERFACILITY TYPE:
740
ADDRESS:183 THIRD AVENUETELEPHONE:
(619) 205-4100
CITY:CHULA VISTASTATE: CAZIP CODE:
91910
CAPACITY:560CENSUS: 265DATE:
07/25/2024
UNANNOUNCEDTIME BEGAN:
12:25 PM
MET WITH:Corinna NortonTIME COMPLETED:
12:54 PM
ALLEGATION(S):
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Resident's room passageways are obstructed
Staff is not following resident's special diet
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ramon Serrano conducted an unannounced complaint visit to deliver findings on the above allegations. LPA met with Director of Resident Services Corinna Norton and we discussed the purpose of the visit and elements of the complaint.

Community Care Licensing (CCL) has investigated the above allegations. The investigation consisted of LPA observation, records review and interviews with facility staff.

It was alleged that Resident 1's (R1) (an LIC 811 Confidential Names List was provided to the facility representative to identify the resident) room passageways were obstructed. It was reported that R1 had recently moved into a room in the assisted living section and R1's "move-in" boxes were still stacked throughout the room. LPA reviewed internal facility notes dated May 28, 2021. Facility contact notes indicate R1 hired a professional moving company to assist with delivery and unpacking on June 23, 2021.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) -76-2306
LICENSING EVALUATOR NAME: Ramon SerranoTELEPHONE: (619) 458-2583
LICENSING EVALUATOR SIGNATURE:

DATE: 07/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 08-AS-20210706135019
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: FREDERICKA MANOR
FACILITY NUMBER: 374603402
VISIT DATE: 07/25/2024
NARRATIVE
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On June 22, 2021 the moving company received an email from R1 indicating that R1 wanted to remove the "unpacking" from their service. The moving company confirmed with R1 that R1 wanted to remove the "unpacking" service since the facility did not provide any unpacking services. Facility contact notes reveal that R1 was in regular communication with facility staff and outside vendor regarding R1's move to the assisted living section of the facility as well as R1's room accommodations. It should be noted that the R1 expressed a desire for facility staff to unpack R1's boxes. However, upon review of the admission agreement, it was confirmed that there was no explicit provision for staff unpacking boxes and personal belongings as part of the facility's services. This aspect was clarified through ongoing communication with R1 during the move-in process.

It was alleged that staff were not following R1's special diet. It was reported that R1 had a "low carb diet" but staff continued to give R1 foods high in carbohydrates which caused R1's blood sugar levels to rise. LPA reviewed R1's meal order forms dated June 28, 2021 through August 22, 2021. R1's meal order forms revealed that R1 had the option of ordering "low carb" meals. Further review of the forms revealed an example of what R1 ordered for lunch; beef barley soup and crackers, ham and provolone and carrot and jicama sticks. An example of what R1 ordered for dinner; tossed salad, Salisbury steak and mixed vegetables. Review of dietary records and internal emails dated May 2021 through August 2021 revealed the Director of Dining Services was in regular communication with R1 regarding R1's special diet and R1's food options. Records review revealed R1's special diet was generally followed as prescribed, although R1 could select any items from the menu R1 desired, including carbohydrates.

LPA Interviewed Director of Resident Services (DRS) who stated that R1 was at the facility less then six months. DRS stated that R1 was offered moving and unpacking services from a vendor that the facility utilized but R1 refused. DRS stated that R1 was unhappy with the facility meals and as a result the Director of Dining Services would sit down with R1 on a regular basis and R1 would select food items that met her dietary needs.

Based upon the foregoing, the above listed allegations are unsubstantiated. This finding means that the preponderance of the evidence standard has not been met and the allegations are not valid.

An exit interview was conducted with Corinna Norton. A copy of this report along with licensee rights (LIC 9058, 3/22) was provided to Corinna Norton whose signature below verifies receipt of these rights.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) -76-2306
LICENSING EVALUATOR NAME: Ramon SerranoTELEPHONE: (619) 458-2583
LICENSING EVALUATOR SIGNATURE:

DATE: 07/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2024
LIC9099 (FAS) - (06/04)
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